Chiropractic Strategies Group, Inc.
1919 Veterans Memorial Blvd., Ste. #200
Kenner, LA 70062
(504) 201-3919 · michael@chiropracticstrategies.com

New Patient Information Form

Please complete this form before your first visit. Do not use this form for emergencies.

Patient Information

Full legal name

Preferred name

Date of birth

Pronouns

Marital status

Street address

City, state, ZIP

Phone

Emergency contact and relationship

Emergency contact phone

Reason for Visit

Primary concern

When did it begin?

How did it begin?

Areas of concern:

NeckUpper backLower backShoulderHipOther

How does it affect daily activities?

What would you most like to improve?

Health History

Previous injuries, surgeries, hospitalizations, or significant conditions:

Current medications and supplements:

Known allergies:

Previous chiropractic, physical therapy, or related care:

Acknowledgment

I certify that the information provided is accurate to the best of my knowledge. I understand that completing this form does not confirm an appointment or establish a provider-patient relationship.

Patient or guardian signature

Date